Inspection on 07/09/07 for 111 Hempstead Road

This inspection was carried out on 7th September 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found no outstanding requirements from the previous inspection report, but made 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

111 Hempstead Road 06/09/06

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Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOME ADULTS 18-65 111 Hempstead Road 111 Hempstead Road Hempstead Gillingham Kent ME7 3RH Lead Inspector Marion Weller Key Unannounced Inspection 7th September 2007 09:50 111 Hempstead Road DS0000067422.V346393.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address 111 Hempstead Road DS0000067422.V346393.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. 111 Hempstead Road DS0000067422.V346393.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 111 Hempstead Road Address 111 Hempstead Road Hempstead Gillingham Kent ME7 3RH 01634 363750 Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) MCCH Society Ltd Care Home 2 Category(ies) of Learning disability (2) registration, with number of places 111 Hempstead Road DS0000067422.V346393.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 6th September 2006 Brief Description of the Service: 111 Hempstead Road is a 3 bedroom semi-detached bungalow that has a small front and rear garden with grassed areas, trees and a patio. The home is set in a residential area close to Hempstead Valley shopping centre with supermarket, cafes, shops and restaurants. The home has easy and close access to a convenience store, Chemist, Library and Public House. The home is fully wheelchair accessible. The nearest public transport is available from the shopping centre. Fees start at £1379 per week and are agreed according to assessed personal need. Please contact the home’s Team Leader if you require further information. 111 Hempstead Road DS0000067422.V346393.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key unannounced inspection was conducted by Marion Weller, Regulatory Inspector, who was in 111 Hempstead Road on Friday 7th September 2007 from 09.50 a.m. until 2:00 pm. During that time the Inspector spoke with the team leader, staff and one of the residents. Some judgements about the quality of life within the home were taken from observations and conversation. Some records and documents were looked at and the home’s Annual Quality Assurance Assessment (AQAA) was also used as a source of information. In addition, a tour of the premises was undertaken. Due to the nature of the service it was not possible to accurately incorporate residents views in the report therefore some further conversations were held with local commissioning staff after the site visit had concluded. Staff gave their full co-operation throughout the inspection. What the service does well: What has improved since the last inspection? The homes statement of purpose has been updated to include changes and details of developments to better inform people about the service provided. Work has started on developing pictorial, resident friendly support/ care plans which will ensure individuals are better involved in the way they are cared for and supported. Nutritional assessments have been introduced for resdients to ensure they receive a healthy balanced diet. An auditing/ handover record for medication has been introduced to further 111 Hempstead Road DS0000067422.V346393.R01.S.doc Version 5.2 Page 6 ensure the security of medicines held in the home. In the residents lounge some of the aged furniture noted on the last inspection report has been replaced to update the environment and make residents more comfortable. An informal concerns and compliments book is available for visitors to complete in the home. A new fire risk assessment has been completed which complies with the demands of new legislation. A staff training analysis has been introduced, designed to identify staff training needs and ensure training is subsequently arranged so that people have the right skills and the knowledge for the tasks they are expected to do. All staff have received updated refresher training in adult protection issues since the last site visit. The home’s team leader has obtained an NVQ level 4 in care and the RMA qualification within the last year. What they could do better: Due to the changing needs of both residents staff should have a good understanding of the ageing process and an awareness of the National Minimum Standards for older people. Some concerns were raised by commissioning staff that the two individuals, who live together in the home, do not particularly like each other. This unfortunate situation may need to be re-examined both by resident’s representatives and provider staff. All parties must be sure current arrangements are to the benefit of both individuals accommodated. Some improvements to the home’s medication administration systems would benefit residents and ensure they are not placed at risk. Residents would benefit from the physical environment of the home being updated and refurbished. Improvements to the communal bathroom would ensure infection control measures in the home are fully met and any potential risk to resident’s health and welfare is eliminated. A programme of routine maintenance and renewal of the fabric and decoration of the premises should be produced by the provider and implemented with records kept in the home. It would be of benefit to residents if maintenance concerns and environmental issues were dealt with, with greater efficiency, particularly for issues such as redecoration and refurbishment, where lines of responsibility and accountability for action are not immediately clear. 111 Hempstead Road DS0000067422.V346393.R01.S.doc Version 5.2 Page 7 Residents would benefit from the team leader responsible for the day-to-day management of the home being registered with the Commission and enabled by MCCH to provide a consistent presence there. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. 111 Hempstead Road DS0000067422.V346393.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection 111 Hempstead Road DS0000067422.V346393.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12345 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use this service have sufficient information about the home in order for them or their representatives to make an informed decision about whether the service is right for them. The personalised needs assessment means peoples diverse needs are identified and planned before they move to the home and they have a contract, which clearly tells them about the service, they will receive. Individuals can be confident the home can meet their needs. EVIDENCE: The home has a comprehensive statement of purpose and pictorial service user guide which clearly sets out the aims and objectives of the service, details the facilities provided and is designed to meet the specific needs of current resdients. The statement of purpose has been updated to include the change of service provider and recent service developments. The home’s Team Leader explained that over the next 12 months they intend to make further improvements to the service users guide, in order to make it 111 Hempstead Road DS0000067422.V346393.R01.S.doc Version 5.2 Page 10 easier for people who use the service to understand, and will be providing them with their own copies. Additionally, they intend to provide resources so the home’s information documents and the current inspection report can be displayed within the main entrance hallway for residents and visitors to access. The current residents have been living at the home for a long time and there are no plans for either of them to leave in the near future. The home has not received any referals since the change of provider in April 2005 and currently has no vacancies. The home’s Team leader was able to go through the admission policy they would follow if a vacancy arose. This included an assurance that a prospective residents aspirations and needs would be comprehensively assessed prior to admission. The explanation clearly met good practice guidelines and the providers published policy and procedure in relation to new admissions. Both service users at the home have a support contract in place as provided by MCCH Society Ltd. 111 Hempstead Road DS0000067422.V346393.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 679 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents have individual care and support plans that ensure their needs are identified and met. They are supported to take assessed risks as part of an independent lifestyle and to make decisions in their lives. EVIDENCE: Current Residents had individual care and support plans based on their assessment of need. Both were inspected in detail. One was in a pictorial format which ensured the indivudual was involved as much as possible in making decisions about the care and support they received. Individual plans clearly identified what care and support was to be given and how. Care Plans evidenced regular review dates and where required they had been developed in conjunction with other relevant health care professionals. Residents are supported to take reasonable risks to allow them to participate in the activities they wish to. All risks had been appropriately assessed and kept 111 Hempstead Road DS0000067422.V346393.R01.S.doc Version 5.2 Page 12 under review. Both residents had recently had communication passports and health action plans implemented in addition to existing care/ support plans. The home had a pictorial menu planning system in place which one resident was supported to use. There were sound reasons for not introducing this system to everyone who lives in the home. The Team leader said that over the next 12 months there are plans to implement and develop budgeting plans for both residents and to work with families/ representsatives regarding their wishes in the event of serious illness or death of a resdient. It was further recommended by the inspector that due to the advancing age of both people who live in the home, staff should be made aware of the ageing process and how advancing years may impact on the indivudals they care for. The ageing process should be included in future training plans and staff shoud also be aware of the National Minimum Standards for older people. 111 Hempstead Road DS0000067422.V346393.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12 13 14 15 16 17 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Residents have opportunities for personal development and take part in appropriate activities. They are very much part of the local community and maintain contact with family members. Residents are offered a healthy nutritious diet and enjoy their meals. EVIDENCE: Both residents maintain contact with their families on a regular basis, including telephone calls, visits to the home and home visits. There are communication passports within residents care /support plans which promote independence and life skills, leisure activities, daily routines and identify any restrictions placed upon them or areas of risk. Risk assessments 111 Hempstead Road DS0000067422.V346393.R01.S.doc Version 5.2 Page 14 are undertaken and recorded. Residents are supported to take reasonable risks to allow them to participate in the activities they wish to. Residents participate in activities mainly on an individual basis due to their differing likes and dislikes. One resident attends an adult educational course for arts and crafts, and hydrotherapy as part of their individual health development plan. Some concerns were raised by commissioning staff that the two people, who live together in the home, do not particularly like each other. This unfortunate situation may need to be re-examined both by resident’s representatives and provider staff. All parties must be sure the current arrangements are clearly to the benefit of both individuals accommodated. Both individuals are supported to use local facilities including a general store, bank, public house, library and shopping centre. They have built up neighbourly relationships within the local community, as a result of frequent access to the services and facilities nearby. The rules of the home respects resident’s rights to privacy, all bedrooms doors are fitted with locking devises. Residents are encouraged to be involved in the day to day running of the home as far as they can be and they have access to all areas of the bungalow. Residents mail is opened only with their permission and within their presence; one service user has a limited level of understanding and is unable to communicate his agreement, in this circumstance staff open his mail on his behalf and record this within his daily record. Both residents have a care/support plan which covers eating, drinking and meal times and provides details of the support needed and particular preferences, one resident has a plan for dietary needs, based upon a speech and language therapist assessment. Both residents have a nutritional assessment in place. The home is also researching a system that will enable them to asses the nutritional content of the menus chosen by resdients. The current nutritional assessments for resdients monitors and records significant signs of loss or weight gain and the document demonstrates the actions which need to be taken by the home in either case. 111 Hempstead Road DS0000067422.V346393.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18 19 20 21 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Residents receive personal support in the way they prefer and they can be confident that their health care needs will be met in full. Residents are largely protected by the homes procedures for managing medication administration. Some improvements to the home’s current facilities and adjustments to procedures would further benefit residents and ensure they are not placed at any risk. EVIDENCE: The home’s medication administration systems and records were inspected. The home has a medication risk assessment in place and a medication policy and procedure document for staff to follow. All staff are adequatly trained. Evidence was seen that staff receive epilepsy and general medication training with refreshers every three years, and rectal diazepam training annually. The home uses a Monitored Dosage System (MDS) supplied from a local pharmacy. Neither resident currently self medicates. 111 Hempstead Road DS0000067422.V346393.R01.S.doc Version 5.2 Page 16 The home could not evidence records of ambient room temperatures for medicine storage and neither do they have a dedicated lockable drugs fridge for cold storage of medicines. They must keep regular temperature records and evidence that they have risk assessed the decision not to provide dedicated equipment based on an assessment of vulnerability and risk to residents. Some signature gaps were noted in MAR sheets. The Team Leader explained that it is normal practice for senior staff to audit MDS sheets and ask the person who left the gap to sign retrospectively. Medication must be signed for at the time of administration otherwise procedures designed to protect residents are being compromised. This must be addressed without delay. An auditing/ handover record for medication has been introduced. This is good pracrice and commendable. The home’s wooden medication cupboard is secured to the wall in the main entrance hall. This would be more secure if it were placed elsewhere in the home and at the same time replaced with one of metal construction as good practice demands. Removal would also make the entrance hall look more homely for residents. The home’s team leader does not currently complete regular competency testing of designated medication administrators or maintain formal records of these events. This should be arranged. Improvements to medication administration in the home was discussed with the team leader. It will be a requirement on this report that where shortfalls exist the provider rectifies them to protect residents from any potential for harm. Both resdients have a health action plan in place and relevant care and support plans for health and hygiene. Health Support is provided to the service users via their GP. This includes annual health checks. Health/ support needs are also assessed and reviewed by the individuals care manager every six months as part of their care plan review. Personal care needs are supported in private, and gender support plans are in place. Designated key workers and co key workers are in place for both service users. As mentioned previously staff should be more aware of the NMS for Older People. Both individuals resident at the home are now over 65 years of age. The home continuies to meet their needs at this point in time and the inspector left with no concerns. The team leader stated the issue of advancing years has been fully discussed with the resdients Care Manager at review and will continue to be closely monitored to both individuals benefit. 111 Hempstead Road DS0000067422.V346393.R01.S.doc Version 5.2 Page 17 111 Hempstead Road DS0000067422.V346393.R01.S.doc Version 5.2 Page 18 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who live in the home have their views listened to and they are protected from abuse, neglect and self-harm. EVIDENCE: There have been no complaints received by the home or by the Commission in respect of the home. The home’s complaints procedure is detailed within the service user guide and is also displayed in the homes main hall way. Residents appeared comfortable expressing their views to staff and were paid attention to and understood. Residents care/ support plans and risk assessments are in place which comprehensively cover abuse and protection issues. Staff have received refresher training in safeguarding vulnerable adults since the last inspection and the home has a copy of the revised Kent and Medway Adult protection policy. There have been no adult protection alerts raised in the home. Staff induction and training records show they have a good understanding of what constitutes abuse and equally understand their responsibilities for reporting allegations on to the correct agencies. All finances are recorded and each resident had an individual finance book and lockable cash tin. Medway Council are the residents appointees and manage 111 Hempstead Road DS0000067422.V346393.R01.S.doc Version 5.2 Page 19 their main accounts. residents receive their personal allowance and mobility DLA component on a four weekly basis. The Manager/ staff carry out regular checks of finances, normally monthly and Medway Council audit resdients finances on a yearly basis. 111 Hempstead Road DS0000067422.V346393.R01.S.doc Version 5.2 Page 20 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 25 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents live in a largely comfortable and homely environment that meets their needs but would clearly benefit from some areas of the bungalow being refurbished and updated. Improvements to the communal bathroom would ensure infection control measures in the home are fully met and the potential to place residents at risk is eliminated. EVIDENCE: 111 Hempstead Road is a 3 bedroom semi-detached bungalow that has a small front and a medium sized rear garden with some small out buildings, trees and a patio area. The garden can be accessed via the homes lounge. A gardener visits on a two weekly basis as arranged via Advance Housing, to cut the lawn and undertake any other garden maintenance. 111 Hempstead Road DS0000067422.V346393.R01.S.doc Version 5.2 Page 21 The home was clean and tidy and free from any offensive odours on the day of the inspection. The two bedrooms used by residents were adequately furnished and they had personal belongings on display. The bedroom nearest the entrance had some wallpaper peeling off and was in need of re-decoration. The carpet in this room is aged and requires changing. These issues were noted during the Commissions previous inspection in 2006 and yet no action appears to have been taken by the provider. The team leader explained that the provider has a 5-year rolling programme of redecoration and refurbishment. The team leader did not have a copy to show the inspector. It will be a requirement in this report that MCCH Society Ltd provide the Commission with a copy of the redecoration/ refurbishment programme for the home and for redecoration work to be scheduled where it is necessary without any further delay. Some of the aged furniture noted in the last report had been replaced in the residents lounge to update the room and make residents more comfortable. A new fire risk assessment has been completed which complies with the demands of new legislation. Fire door guards, as recommended during a recent internal health and safety audit were fitted to all fire doors in the home on the 15/08/07. The home uses a third bedroom as a staff ‘sleep in’ room/ office which can also be utilised as a private area for visitors etc. The home has a loungedinner, and an ample sized kitchen. The resdients communal bathroom is in need of refurbishment. The bath panel was broken and the seal between the bath and the wall was in poor condition. Some tiles had been replaced, others were cracked. The current situation makes cleaning the area dificult and compromises the home’s infection control policy. The broken areas can place resdients at risk of skin tears and other such injuries. It will be a requirement in this report to address the infection control issue. The room that is now used as a staff/ ‘sleep in’ room, the residents communal bathroom and lounge all have a track and hoist system that is owned by the home but not required by either resident. Serious consideration should be given to having this removed. It does nothing to make the environment feel particularly homely and it intrudes on residents’ communal space. Maintenance work for the bungalow, including emergency repairs are undertaken under the management of Advance Housing. The service to residents is however provided via MCCH Society Ltd. This situation is somewhat confusing and leads to some lack of clarity over who is responsible for taking action about environmental issues which do not fall directly into the 111 Hempstead Road DS0000067422.V346393.R01.S.doc Version 5.2 Page 22 ‘emergency’ or ‘maintenance’ category. Redecoration is a case in point. The team leader explained in the home’s Annual Quality Assurance Assessment recently that it would be an improvement if maintenance concerns and environmental issues were dealt with, with greater efficiency, particularly for issues where responsibility is not clear. The inspector would fully support that view. 111 Hempstead Road DS0000067422.V346393.R01.S.doc Version 5.2 Page 23 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32 34 35 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Residents benefit from a competent and qualified staff team who understand their roles and responsibilities. They are further protected by the home’s robust recruitment practices. EVIDENCE: All staff have a job description, and where it is relevant, agreed guidelines are in place for areas of additional responsibility, such as key working. Each resident has a key-worker who is responsible for ensuring appointments are made and kept with health services and significant others including care managers for reviews, monthly evaluation of care/ support plans and purchasing of clothes. Many of the current staff team have worked at the home for a number of years, and those spoken with were able to evidence a good awareness of residents needs. There have been some ongoing vacancies on the staffing 111 Hempstead Road DS0000067422.V346393.R01.S.doc Version 5.2 Page 24 rosters due in part to long term sickness of substantive staff. As the situation became protracted, the team leader organised a small group of MCCH bank and agency staff to cover vacant hours. Both residents knew these individuals and thus continuity of care during that period was assured. Plans were discussed to appoint a senior support worker, and obtain a regular member of bank staff to cover long-term staff sickness in future. Work had begun on a bank/ agency reference book to assist unfamiliar staff who may be required to work at the home. The plan is for the document to contain all of the relevant information needed in one place and to provide a reference point for all staff to access information. All of the current staff team have achieved or are working towards a minimum of NVQ level 2. The home exceeds the required standard of 50 of trained staff, which is designed to ensure that residents are in safe hands at all times. Staff receive regular planned supervision. Records of these sessions and annual appraisal records were viewed in staff files. Staff training needs are routinely discussed and assessed. The home had a training matrix, which had been updated at regular periods. The team leader explained that she is intending to apply for equal opportunities and diversity training for the whole staff team over the next 12-month period. Staff files inspected indicated residents were being protected through the use of robust staff recruitment procedures. Staff were only employed after necessary references and checks had been obtained and these were found to be satisfactory. 111 Hempstead Road DS0000067422.V346393.R01.S.doc Version 5.2 Page 25 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37 39 42 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Residents benefit from having a person in charge that provides clear leadership, is qualified and competent and whose aim is to consistently improve and develop the service and outcomes for residents. They would benefit further from the individual being registered with the Commission and enabled by MCCH to provide a consistent presence at the home. EVIDENCE: The team leader in charge of day-to-day management of the home is not registered with the CSCI at present. She currently divides her time between this and another home owned by the same provider. This is not the best arrangement for residents in either home and should be seriously reconsidered. 111 Hempstead Road accommodates two highly dependent and 111 Hempstead Road DS0000067422.V346393.R01.S.doc Version 5.2 Page 26 ageing services users who require a consistent management presence to promote and ensure their welfare and support staff. The team leader has directly managed the service for five years and has worked within differing care provision settings since 1997. She has an NVQ Level 4 in Care, A Registered Managers Award, Introductory Certificate in Management Level 3 and the Assessors Award D32-33. It was evidenced that she had undertaken periodic training as required of her role, such as gaining the Intermediate Certificate in Supervising Health and Safety. She gives a clear sense of leadership, is highly respected by staff and resdients clearly benefit from her presence in the home. The homes has a dedicated health and safety representative who liases and supports the manager with health and safety management in the home. There is a policy/ procedure and risk assessment in place for all safe working practice areas covered by the minimum standards 42.2.and 42.3. Up to date records are in place demonstrating evidence of PAT testing, electical hard wiring, and servicing of the boiler. Certificates and licences are obtained and filed or displayed at the service as appropriate. Equipment was seen to have been regularly serviced and fire drills carried out. All staff have received training in general health and safety issues. Some courses are booked for staff to update their infection control training. Residents are involved as much as possible in the everyday running of the home. The provider sends questionnaires to residents and their relatives/ representatives on occasion to gather their views about the home. The provider makes regular visits to the home to check the quality of the service being provided. Records of these visits were briefly viewed. There are some issues of health and safety, which cause concern and have been detailed in this report. These are predominantly environmental although some minor medication administration shortfalls also require address. 111 Hempstead Road DS0000067422.V346393.R01.S.doc Version 5.2 Page 27 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 3 3 3 4 3 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 2 26 X 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 3 3 X 3 X X 2 X 111 Hempstead Road DS0000067422.V346393.R01.S.doc Version 5.2 Page 28 NO Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA20 Regulation 13 (2) Requirement The Registered person shall make arrangements for the recording, handling, safekeeping, safe administration and disposal of medicines received into the care home. In that: The shortfalls in medication administration detailed in the report must be addressed by the timescale given if not sooner. 2. YA30 YA42 13 (3) The registered person shall make suitable arrangements to prevent infection, toxic conditions and the spread of infection at the care home, In that: • The broken bath panel in the residents’ communal bathroom must be replaced within the timescale given. • The damaged bath seal and the broken tiles surrounding the bath must be replaced and made good within the timescale Version 5.2 Page 29 Timescale for action 31/12/07 31/12/07 111 Hempstead Road DS0000067422.V346393.R01.S.doc given if not sooner and maintained thereafter. 3. YA24 23 (2) (d) (5) 16 (2) j The location and layout of the home must be suitable for its stated purpose; it must be accessible, safe and well maintained; meet service users’ individual and collective needs in a comfortable and homely way. A programme of routine maintenance and renewal of the fabric and decoration of the premises must be produced and sent to the Commission by the timescale given and implemented with records kept. 31/12/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA21 Good Practice Recommendations It is strongly recommended that staff are made aware of the ageing process and the National Minimum Standards for older people due to the advancing years of both resdients accomodated. It is strongly recommended that the bedroom nearest the front door be redecorated and the carpet replaced without further delay. Serious consideration should be given to removing the ceiling track system in the home. It does nothing to make the environment feel particularly homely at 111 Hempstead Rd, is not required by either resident accommodated and intrudes on resident’s communal space. 2. 3. YA25 YA24 111 Hempstead Road DS0000067422.V346393.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Maidstone Local Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI 111 Hempstead Road DS0000067422.V346393.R01.S.doc Version 5.2 Page 31 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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